Exercise and antidepressants improve fibromyalgia

Journal of Family Practice, April, 2004 by Anna Quisel, James Gill, Dene Walters

TABLE 1

Aerobic exercise for fibromyalgia: the evidence

Aerobic exercise (SOR: A)

Study (LOE)        Treatment specifics          Results

Busch et al (49)   Supervised aerobic trai-     Benefits over controls:
(1)                ning--eg, aerobic dancing,   improvements in
                   stationary cycling,          aerobic performance,
                   walking: 1) frequency of     tender points, and
                   2 days per week,             global well-being.
                   2) intensity sufficient to
                   achieve 40%-85% of heart     Adverse effects:
                   rate reserve or 55%-90%      poorly reported.
                   predicted maximum heart
                   rate, 3) duration of
                   sessions of 20-60 minutes
                   duration, either conti-
                   nuously or intermittently
                   throughout the day, and
                   using any mode of aerobic
                   exercise, 4) total time
                   period of at least 6
                   weeks, maximum 1 year in
                   these studies.
Sim et al (50)     Not standardized, but 3      Benefits over controls:
(2)                studies set exercise         preliminary evidence
                   intensity at 60%-75% of      for improvements in
                   max. heart rate. Duration    symptoms.
                   6 weeks to 20 weeks.
                                                Adverse effects:
                                                not reported.

Rossy et al (51)   Loosely defined and          Benefits over controls:
(2)                heterogeneous, including     improvement in
                   "exercise, strengthening,    physical status,
                   walking, stretching, pool    fibromyalgia
                   therapy, cycling, swim-      symptoms, and
                   ming, and aerobics."         psychological status
                                                with effectiveness
                                                comparable with
                                                pharmacologic
                                                treatment for arthritis
                                                pain.

                                                Adverse effects:
                                                not reported.

Study (LOE)        Comments

Busch et al (49)   4 high-quality aerobic
(1)                training studies
                   included in meta-
                   analysis. No
                   significant
                   improvements in pain
                   intensity, fatigue,
                   sleep, and psycho-
                   logical function.
Sim et al (50)     Heterogeneous
(2)                studies.
Rossy et al (51)   Heterogeneous
(2)                studies. No
                   improvement in daily
                   functioning.

SOR, strength of recommendation; LOE, level of evidence. For an
explanation of these ratings, see page 268.

TABLE 2

Alternative nonpharmacologic
therapies for fibromyalgia: the evidence

Multidisciplinary rehabilitation
(physician and psychological, social, or vocational interventions)
(SOR: C)

Study (LOE)          Treatment specifics        Results

Karjalainen          Education plus physical    Benefits over controls:
et al (52) (2)       training vs education;     not significant.
                     education plus cogni-
                     tive treatment vs          Adverse effects:
                     education and group        not reported.
                     discussion; behavioral
                     therapy vs education;
                     stress management vs
                     aerobic exercise.

Acupuncture (SOR: B)
Berman et al (53)    Systematic review.         Benefits over placebo:
(2)                                             improvements in pain,
                                                stiffness, global
                                                improvement.
                                                Adverse effects: pain
                                                with needle insertion.

Study (LOE)          Comments

Karjalainen          Heterogeneous
et al (52) (2)       studies. No high-quality
                     randomized controlled
                     trials identified.

Acupuncture (SOR: B)
Berman et al (53)    Only 1 randomized
(2)                  controlled trial. No
                     long-term results.

SOR, strength of recommendation; LOE, level of evidence. For an
explanation of these ratings, see page 268.

TABLE 3

Antidepressant therapy for fibromyalgia: the evidence

Antidepressants (SOR: A)

Study (LOE)            Treatment specifics       Results

Arnold et al (55)      Tricyclic antidepres-     Benefits over placebo:
(1)                      sants:                  significant response
                       Amitriptyline 25-50 mg    in 25%-37% of patients
                         daily (n=4 trials)      with moderate
                       Dothiepin 75 mg daily     improvements in sleep,
                         (n=1)                   pain, and global
                       Cyclobenzaprine 10-40     assessment by patient
                         mg daily (n=4)          and physician, and
                       Clomipramine 75 mg        modest improvements in
                         daily (n=1)             fatigue tenderness and
                       Maprotiline 75 mg         stiffness.
                         daily (n=1)
O'Malley et al (54)    Amitriptyline 50 mg       Benefits over placebo:
(2)                      daily (n=8 trials)      number needed to treat
                       S-adenosylmethionine      of 4 with moderate
                         200-800 mg daily        improvements in sleep,
                         (n=2)                   overall well-being,
                       Cyclobenzaprine 20 mg     and pain severity.
                         daily (PM), 10 mg       Mild improvements in
                         daily (PM) (n=1)        fatigue and number
                       Fluoxetine 20 mg daily    of tender points.
                         (n=2)
                       Citalopram 20 mg daily
                         (n=1)
                       Clomipramine 75 mg
                         once daily (n=1)
Rossy et al (51)       Amitriptyline (n=7        Benefits over placebo:
(2)                      trials)                 improvement in
                       Dothiepin (n=1)           physical status and
                       Fluoxetine (n=2)          fibromyalgia symptoms
                       Citalopram (n=1)          with effectiveness
                       5-hydroxytryptophan       comparable with
                         (n=1)                   pharmacologic
                                                 treatment for
                                                 Arthritis pain.

                                                 Adverse effects:
                                                 not reported.

Study (LOE)            Comments

Arnold et al (55)      Studies short-term,
(1)                    most less than 6
                       weeks. In the only
                       trial of 26 weeks, by
                       the end of the study,
                       the effectiveness of
                       amitriptyline and
                       cyclobenzaprine were
                       no greater than
                       placebo.
O'Malley et a1 (54)    Combined effects
(2)                    from heterogeneous
                       classes of
                       antidepressants.
Rossy et al (51)       Heterogeneous
(2)                    studies. No effect on
                       daily functioning or
                       psychological status.

SOR, strength of recommendation; LOE, level of evidence. For an
explanation of these ratings, see page 268.